Employer Group Proposal Request for High Deductable Health Plan

Complete the form below and press the Submit Propsal Request button at the bottom. An agent will contact you with your quote. Please be assured that your information will be kept strictly confidential in accordance with our privacy policy, and will not be sold for any purpose.

* required
Company Information
Contact Name:
*
Business Name:
*
Type of Business:
*
Address:
*
City:
*
State:
Zip Code:
*
County:
Email:
*
Phone Number:
*
Fax Number:
Best time to call:
# of Employees you wish to insure:
# of Full-Time Employees working
    over 30 hours:
Current Company Group Plan
If your company does not currently have a health plan, please skip this section
Please indicate the type of health plan?:
Traditional (No PPO Network)
PPO Network
HMO Plan
HSA Plan
HRA Plan
Other (Describe in Comments Section)
Name of Insurance Company:
Current Monthly Premium:
Doctor's Office Co-Pay:
Prescription Co-Pay or % - Generic:
Prescription Co-Pay or % - Brand:
Deductable Amount:
After the Deductable:
100% 90/10% 80/20% 70/30% 50/50%
Vision
Yes No
Dental
Yes No
Disability
Yes No
Life
Yes No

Comments:




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